Nursing Telephone Follow-up to Reduce 30-day Readmissions and Post-discharge Complications for the Adult Hemodialysis Patient

Author:
Briscoe, Gordon, Nursing Practice - School of Nursing, University of Virginia
Advisor:
Quatrara, Beth Ann, UVA Health System, University of Virginia
Abstract:

Recurrent hospital readmissions are responsible for considerable health care costs, with readmission rates in patients with end stage renal disease (ESRD) remaining as high as 35.2% within 30 days of discharge (USRDS, 2014). Studies have shown that a considerable percentage of readmissions are preventable through effective discharge planning and patient follow-up after discharge (Mistiaen & Poot, 2006). Providing telephone follow-up (TFU) is a high-quality, low cost method of providing health information, advice, and the recognition of complications early after hospital discharge (Mistiaen & Poot, 2006). This project examined the effectiveness of an evidence-based quality improvement process implemented in an Acute Inpatient Renal Unit providing post-discharge telephone follow-up by experienced dialysis nurses. To enhance the experience of the dialysis patient’s transition from an acute care setting to a home setting, a series of systematic processes were implemented to standardize unit workflow, in addition to utilization and leveraging of the hospital’s electronic medical record (EMR) system to document patient post-discharge progress and outcomes, using a scripted telephone follow up procedure. This quality improvement project compared pre-intervention data to post-intervention data to evaluate the impact on 30-day readmissions and post-discharge complications in a sample of adult hemodialysis (Stage 5 CKD & ESRD) patients. The overall readmission rate decrease by 17% and the 30-day readmission rate decreased by 3.8%. Coordinated and targeted discharge phone follow-up has the potential to benefit this vulnerable patient population.

Degree:
DNP (Doctor of Nursing Practice)
Keywords:
chronic kidney disease, end-stage renal disease, telephone call, post discharge follow-up, 30-day readmissions
Language:
English
Issued Date:
2017/04/25